Provider Demographics
NPI:1093249104
Name:BLACK, RYAN NOEL (LSW)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:NOEL
Last Name:BLACK
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 E WATERLOO RD STE 313
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-3856
Mailing Address - Country:US
Mailing Address - Phone:330-208-2720
Mailing Address - Fax:330-208-2721
Practice Address - Street 1:1560 CORPORATE WOODS PKWY
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685-8730
Practice Address - Country:US
Practice Address - Phone:330-208-2720
Practice Address - Fax:330-208-2721
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1601260104100000X
OHS.16012601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0304759Medicaid